Aim: This paper reports a study to evaluate the contribution of nursing care within an integrated care pathway for patients with hip fracture. Show
Background: There is growing interest in quality assurance in health care. Integrated care pathways are a method to achieve this goal, and are a multi-professional team approach where the requirement for nurses to work effectively within the team is important. However, the nurses' role and contribution within the team have not been well described. Method: A quasi-experimental, prospective study comparing an intervention group with a comparison group was carried out. One hundred and twelve independently living patients, aged 65 years or older and admitted to a Swedish hospital with a hip fracture, were consecutively selected. Pathological fracture and severe intellectual impairment (Pfeiffer's test <3 points) served as exclusion criteria. The intervention was designed to focus on patients' motivation and their prerequisites for rehabilitation and was based on the concept of transition. The main outcome measure was the number of patients restored to preoperative activities of daily living levels in 2003-2004. Findings: In the intervention group 21% were restored to activities of daily living to level A (independent) at discharge, whereas only 5% in the comparison group were restored to this level. No patients in the intervention group, admitted as independent, remained at activities of daily living level F (dependent), whereas 16% remained at level F in the comparison group (P=0 x 003). Conclusion: When admitting older patients with a hip fracture, it is important to acquire good knowledge about each patient and their prerequisites and to offer them accelerated rehabilitation in accordance with their individual ability. By monitoring process indicators during the transition, serious deviations from the care plan can be avoided. The discharge of an older person from an acute hospital to the most appropriate setting following hip fracture surgery is a complex undertaking requiring careful planning and, if ineffectively conducted, can be the weak link in the passage of the patient from one care setting to another. Premature discharge or discharge to an unsuitable environment can result in hospital readmission. Early hospital discharge may not lead to overall cost-savings if it results in the need for more intense subsequent health-care utilisation, such as ED visits or rehospitalisation. Hospital readmissions are often the result of a fragmented health and social care system [] and increasing evidence indicates that patients are particularly vulnerable and more likely to experience negative outcomes during these hospital readmissions []. Many factors that can increase the likelihood of readmission can be modified so need be considered in the way services are designed and developed. Such factors include; premature discharge, inadequate post-discharge support, insufficient follow-up, therapeutic errors including adverse drug events and other medication-related issues, inadequate transfer handovers and complications of hospital procedures and surgery such as nosocomial infections, pressure ulcers and patient falls. The patient and family have a right to be involved and supported at every stage of the process so collaboration and continuity of care are central. It is essential that the older person and their family are adequately prepared for discharge, that a care pathway is activated that continues following discharge and that the role of the family and informal carers as partners in the care team is facilitated []. Development of a discharge plan must begin as early as possible during the hospital stay, to ensure that patient education and support are provided to facilitate independence and so that the patient can develop an understanding of their health condition and acquire the knowledge and skills needed to self-care independently or with caregiver/family support. Patients leaving hospital following hip fracture surgery always need further care. To enable discharge, the health-care team must determine the most appropriate setting for ongoing care, considering the continuing care, medical, functional and social needs, and decision-making capacity of the patient. The MDT should collaborate with the patient/family/caregivers and other stakeholders to determine the most suitable plan. Several factors must be considered including; cognitive status, activity level and functional capacity, current home suitability, availability of informal and formal care, availability of transportation and availability of services for ongoing care. The severity of functional impairments and the need for assistance with activities of daily living (ADLs) often determine whether a patient can be safely managed at home or requires care at a skilled nursing facility (“nursing home”) or extended care facility (“residential home”) with attention to the need for supervision of ADLs and safety awareness. 10.3.1. Discharge HomeFor successful discharge home, patients (with help from family or other caregivers, if available) should be able, as a minimum, to:
Availability of appropriate services in the community can influence whether the patient may be safely discharged home. Home services may allow patients who would otherwise need residential care to manage their care needs at home. The lack of a system that ensures continuity of care following discharge home, or other location, can cause serious errors including adverse medication events []. 10.3.2. Discharge to Another SettingIf discharge home is not appropriate, transfer to another inpatient or residential facility for ongoing care must be arranged. Determining the most appropriate setting for ongoing care involves assessing and matching needs with the capabilities of the potential care setting. One model to help accomplish this involves assessing a set of parameters that describe generic clinical characteristics (medical and surgical issues, mental and emotional status, physical functioning and environment) that are largely independent of the patient’s specific diagnosis. These needs are then matched with the services offered at different types of facilities. Once the care team, patient and family have decided that discharge to an alternate facility is necessary, referrals can be made to facilities that are appropriate and meet the patient and family desires and the patient can be screened for acceptance. Three main types of care facility exist depending on the locality/region/country, each with a different function:
Poor information transfer from hospital-based providers to other facilities is common and can contribute to poor discharge/transfer outcomes including the need for readmission, temporary or permanent disability or even death. Discharge information, both written and verbal, should be reviewed with the patient/family and caregivers with an emphasis on assessing and ensuring comprehension. At discharge, the patient should be provided with a document that includes language and literacy-appropriate instructions and patient education materials to help in successful transition from the hospital. These documents should be brief, focused on critical information for the patient and focused on what the patient needs to understand to manage after discharge. One model for patient materials, developed by the National Patient Safety Foundation [], called “Ask Me 3”, includes the following information: 1.What is my main problem? (Why was I in the hospital?) 2.What do I need to do? (How do I manage at home and what should I do if I run into problems?) 3.Why is it important for me to do this? 10.3.3. The Discharge ProcessA critical issue leading to discharge problems is lack of planning of the discharge itself. The discharge process must begin on admission to allow time and resources for discharge planning. There are three phases that characterise the discharge process: (1) admission, (2) hospitalisation and (3) discharge. The admission phase: Within 48 h of admission, the Blaylock Risk Assessment Screening Score (BRASS), a tool that can be used to identify patients who may require a more comprehensive discharge plan, can be used to identify patients at risk of difficult discharge [] and a referral can be made to the discharge liaison service. The hospitalisation phase: Once a place of discharge has been decided, contact can be made. If discharge is to be to a continuing care facility (rehabilitation/intermediate care unit or nursing/residential home), individuals involved in the admission to the care facility should visit the patient to assess their suitability for the facility and to discuss this with the patient and family. This visit can enable community care professionals or a continuing care manager to undertake a detailed assessment of the patient’s function and need for continuing care interventions. This can be done using a specific measure of function such as the FIM® (Functional Independence Measure), an international standard for the measurement of disability; using cumulative scores produces a quantitative index of the person’s function. The FIM™ score has proven validity as an index of rehabilitation efficacy and can be used in acute hospitals, post-acute rehabilitation hospitalisation, nursing homes and home care. An initial individualised care plan should be developed based on the person’s overall condition and function (degree of pre- and post fracture autonomy, comorbidity, polypharmacotherapy, postfracture conditions, delirium and recovery motivation) and point in the post-hospital trajectory (intensive, extensive rehabilitation). If discharge home is planned, requests for appropriate aids can be made at this time. The education and training of patients and informal caregivers should also begin as soon as possible and continued once the patient is home. The discharge phase: The multidisciplinary team collaborates to devise and operationalise a definitive individualised care plan for discharge. Assessment of the degree of independence and autonomy achieved by the patient during their hospital stay and recovery and their readiness for discharge can be assessed. Important arrangements for transport, follow-up, equipment and drugs should also be made by the discharge coordinator. Ultimately, verification of the patient’s arrival home and that services have commenced will complete the process. If home care is being provided, care will be formally transferred to the health professional who is assigned to the patient and family, the coordinator of the rehabilitation facility or the care leader in the residential care facility. 10.3.4. Continuity of CareContinuity of care has three aims; best quality of care, the best health outcomes for the patient and cost reduction [], and is achieved through: 1.The transfer of information and sharing of the patient’s story with other professionals 2.Timely collection of information and activation of necessary resources immediately following discharge 3.Effective discharge planning 4.Monitoring and accompaniment 5.The assessment of needs of the use and caregivers. Continuity of care can be achieved by one health or social care professional taking responsibility for the transition between care settings and ensuring that effective care is provided throughout the transition while focusing on the person and their family []. Taking this responsibility ensures continuity of care from one operating unit to another and across different levels of the health and social care system. This also ensures that the complex care process is integrated and is led in a way that guarantees that the older person receives a coordinated set of interventions aimed at meeting their complex needs. This enables governance of a complex and integrated care process in its various stages and guarantees that a coordinated set of interventions aimed at satisfying complex needs is in place []. There are several critical issues that can lead to discharge problems:
10.3.5. The Nurse’s Role in DischargeNurses have an important role in ensuring continuity of care between settings and can act as a coordinator, supporting hospital staff involved in the discharge process, reducing hospital readmissions, ensuring continuity of care and educating patients about safety in continued care []. Care that began in the acute hospital should be continued following discharge through specialist nurse-led care in the rehabilitation hospital, intermediate care, home care or residential care setting led by a nurse with masters’ level gerontological education []. In many health systems, a nurse is employed as a case manager or discharge coordinator whose key role is to support discharge planning and negotiating the different parts of care services and formal and informal care networks, particularly during transfer from one service to another. This includes supporting the person who cannot directly, or through a family member, interface with the care networks themselves. The nurse case manager is responsible for []: 1.Care integration: ensuring coherence between what has been planned and what is achieved 2.Coordination of care: ensuring that the care plan is followed by all those involved in its provision 3.Continuity of care: ensuring the implementation of the plan of care across all areas of care. Nurses are the most appropriate health professionals to act as case manager [] and/or discharge coordinator because of:
There are many skills needed by the nurse case manager including; agent of change, clinical knowledge, identification and assignment of cases, consultancy, educator, coordinator and facilitator of care, resource manager and outcome and quality manager and advocate. What are 5 nursing diagnosis?The nurse can conclude a nursing diagnosis based on these symptoms: impaired swallowing. Examples of nursing diagnosis: risk for impaired liver function; urinary retention; disturbed sleep pattern; decreased cardiac output. On the other hand, a medical diagnosis is made by a doctor or advanced health care practitioner.
What are the nursing management of a patient with fracture?Nursing Interventions and Rationale. Maintain bed rest or limb rest as indicated. ... . Secure a bed board under the mattress or place the patient on the orthopedic bed. ... . Support fracture site with pillows or folded blankets. ... . Use sufficient personnel when turning. ... . Observe and evaluate splinted extremity for resolution of edema.. What are the 4 types of nursing diagnosis?There are 4 types of nursing diagnoses: risk-focused, problem-focused, health promotion-focused, or syndrome-focused.
How is a fracture diagnosis?Diagnosis & Tests
X-rays are usually used to confirm if a bone is broken and to find the locations of any loose bony pieces. Other diseases of the bone can also show up on an x-ray, such as osteoporosis, Paget's disease, or compression fractures in the spine.
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